What is the appropriate imaging order for a patient with cervical spine and lumbosacral spine/pelvis pain after a fall?

Imaging Orders for Cervical and Lumbosacral Spine After Fall

For a patient with cervical spine and lumbosacral spine/pelvis pain after a fall, order CT cervical spine without contrast AND CT thoracolumbar spine without contrast as the initial imaging studies. 1

Cervical Spine Imaging Approach

Primary Recommendation: CT Without Contrast

• CT cervical spine without IV contrast is the gold standard for initial trauma evaluation, with sensitivity of 88.6-100% compared to plain radiographs which detect only about one-third of fractures visible on CT 1, 2
• CT significantly outperforms radiographs in identifying cervical spine fractures and is considered the definitive imaging modality for suspected cervical spine injury 1
• Order as: "CT cervical spine without contrast, thin-section with sagittal and coronal multiplanar reconstructions" 1, 3

When Plain Radiographs May Be Considered

• Plain radiographs are largely supplanted by CT and should only be used if CT is unavailable 1
• If radiographs must be obtained, order minimum three views: anteroposterior, lateral, and open-mouth odontoid 1, 4
• However, radiographs have poor sensitivity (identifying only 36.4% of injuries) and are inadequate for ruling out cervical spine injuries in trauma patients 1, 2

Follow-Up MRI Indications

• MRI cervical spine without contrast should be added if: 1, 2
  • Neurological deficits are present despite negative CT
  • Patient remains symptomatic with persistent neck pain after negative CT
  • Ligamentous injury is suspected (CT is inferior to MRI for soft-tissue injuries including epidural hematoma, cord contusion, and ligament sprains) 1
  • Patient is obtunded and cannot be clinically cleared 2, 4

Lumbosacral Spine/Pelvis Imaging Approach

Primary Recommendation: CT Without Contrast

• CT thoracolumbar spine without contrast is the initial imaging of choice for suspected thoracolumbar spine injury after trauma 1
• CT has sensitivity of 94-100% for identifying thoracolumbar spine fractures compared to radiographs with only 49-62% sensitivity for thoracic and 67-82% for lumbar fractures 1
• Order as: "CT thoracolumbar spine without contrast" or utilize reconstructions from CT abdomen/pelvis if already obtained 1, 3

Clinical Criteria Warranting Imaging

Any patient meeting these criteria requires thoracolumbar imaging: 1

• Midline thoracolumbar tenderness on examination
• High-energy mechanism of injury (fall from height)
• Age >60 years
• Altered consciousness (GCS <15), intoxication, or distracting injury preventing adequate examination

Why Not Plain Radiographs

• Radiographs miss 25-52% of thoracolumbar injuries compared to CT 1
• Clinical examination alone has poor sensitivity (48-75%) for identifying thoracolumbar injuries 1
• Plain radiographs should not be used for initial trauma screening of the thoracolumbar spine 1

Critical Pitfalls to Avoid

Screen the Entire Spine

• Approximately 20% of spine injuries have a second noncontiguous spinal injury at another level 1, 2
• If cervical injury is found, image the entire spine; if thoracolumbar injury is found, image the cervical spine 1

Do Not Rely on Plain Films

• Using radiographs as initial screening misses significant injuries that CT readily detects 1, 2
• The "three-view cervical spine series" is outdated and inadequate for trauma evaluation 1

Do Not Skip MRI When Indicated

• Persistent neck pain despite negative CT may indicate ligamentous injury requiring MRI 1, 2
• Less than 1% of patients will have cervical spine instability on MRI not appreciated on CT, but these injuries are clinically significant 1

Contrast Is Not Needed

• Do not order CT with IV contrast for initial trauma evaluation—it provides no additional value and can make subtle fractures harder to detect due to contrast superimposition 1

Sample Order Format

For cervical spine:

• "CT cervical spine without IV contrast, thin-section with multiplanar reconstructions"

For lumbosacral spine/pelvis:

• "CT thoracolumbar spine without IV contrast" or "CT lumbar spine without IV contrast"

If neurological symptoms present or persistent pain after negative CT:

• Add "MRI cervical spine without IV contrast" and/or "MRI lumbar spine without IV contrast"